Coronary artery Dissection. Dr TP Singh MD,DM

Transcription

1 Coronary artery Dissection Dr TP Singh MD,DM

2 52 M,Non HT, Non DM,Acute IWMI lysed within 4 hours D2 Coronary angiography RCA mid 90% discrete hazy stenosis LAD non significant ifi disease, LCx Normal Taken for PCI to RCA

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4 Successful PCI and stenting to RCA done with good flows JR 3.5 Launcher from Medtronic, soft tip guidewire Intracoronary NTG and Nikoran given.

5 Subsequently in next shot proximal RCA was totally t occluded with dissection flap. After 30 mins of strenuous effort entry in true lumen with change of guide cath and soft tip guidewire obtained, and subsequent films obtained.

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7 Stent 3.5x30 Stent 3.5x12

8 Final result

9 Type F dissection: represent those that lead to total occlusion of the coronary lumen without distal antegrade flow. Acute vessel closure is the most feared complication due to coronary artery dissection, and in the pre stent era occurred in up to 11% of all elective PTCAs. With the advent of coronary stents, the incidence of acute closure in elective PCI is now less than 1%. Ischemic complications in the current era usually occur as manifestations of edge dissections after stenting, which may predispose to stent thrombosis.

10 Type A dissections: Minor radiolucent areas within the coronary lumen during contrast injection with little or no persistence ste ceof contrast after the edye has cleared. Type B dissections: are parallel tracts or a double lumen separated by a radiolucent area during contrast injection, with minimal i or no persistence after dye clearance. Tpe Type C dissections: appear as contrast outside the coronary lumen "extraluminal cap" with persistence of contrast after dye has cleared from the lumen. Coronary Artery angiographic changes after PTCA: Manual of Operations NHBLI PTCA Registry :9.

11 Type D dissections represent spiral ("barber shop pole") luminal filling defects, frequently with excessive contrast staining of the dissected false lumen. Type E dissections: appear as new, persistent filling defects within the coronary lumen. Type F dissections: Total occlusion of the coronary lumen without distal antegrade flow. In rare cases, a coronary artery dissection my propagate p retrograde and involve the ascending aorta Coronary Artery angiographic changes after PTCA: Manual of Operations NHBLI PTCA Registry :9.

12 Definite Lft Left main disease The use of Amplatz shaped catheters. Catheterization i for acute myocardial infarction. i Possible Vigorous catheter manipulations. i Vigorous contrast injection. Deep intubations of the catheter Variant anatomy of the coronary ostia. Vigorous, deep inspiration.

13 Choice of guide catheter t and handling techniques Awareness of the potential risk may aid in rapid recognition Appropriately sized and shaped catheters to avoid the contrast t injection being directed d at a plaque. Initial contrast injections should not be forceful until correct coaxial alignment of the catheter has been demonstrated. Contrast should not be injected if the pressure is damped

14 Depend on the patency of the distal vessel and the extent of propagation of the dissection. Acute closure of the artery, urgent revascularization is mandated to prevent infarction. In the absence of acute vessel closure, if there are new ECG changes or chest pain suggesting ischemia, type A or B, conservative strategy can be adopted. Soft tip wires should be used to access the true lumen, and contrast should be injected through an over the wire balloon to confirm the true lumen. If the initial i i attempt fails and enters the false lumen, another soft tip wire should be carefully manipulated into the true lumen, guide may be withdrawn a bit.